​Saving the World from Superbugs- The Worldwide Problem of Antibiotic ResistanceSarju Bharucha, JD, Editor-in-Chief

SafeCare Magazine is proud to honour our 2016 Safe Care Person of the Year, Dr. Otto Cars. Dr. Cars truly embodies the aspirations of the SafeCare Person of the Year through the work of his independent international network ReAct (Action on Antibiotic Resistance). ReAct aims for profound change in awareness and action to manage the interacting social, political, ecological, and technical forces that drive the rising rate of antibiotic-resistant infection and the rapid spread of resistance within and between communities and countries. Congratulations Dr. Cars! In this issue, we are bringing you an exclusive interview with Dr. Cars, who was part of the planning committee and initiated a collaboration with the European Medicines Agency (EMA) and the European Centre for Disease Prevention and Control (ECDC) to carry out the first scientific study to visualize the gap in the availability of new antibiotics in relation to the burden of infections. Dr. Cars is pushing for a global system for surveillance of antibiotic resistance that would allow us to measure the global disease burden caused by resistant superbugs.​

2016 person of the year - otto cars, md, phd

2016​SafeCare ​Person of the Year Saving The World From Superbug Apocalypse - One of the Biggest Health Threats to MankindFull, in-depth interview by The SafeCare Group CEO & Chairman Yisrael M. Safeek, MD, MBA with Cars, MD, MD, Chairman of ReAct Group. ​​​​Yisrael Safeek: Welcome Dr. Cars. You have spent more than 20 years spreading the word about the risks of antibiotic resistance around the world. You are one of the founders and the second president of the International Society of Anti-infective Pharmacology. You are also the founder of the international network ReAct – Action on Antibiotic Resistance. Through Science outreach, you have disseminated evidenced-based information driving the issue of antimicrobial resistance toward political decisions, both national and international. Your twenty plus year work on yielded tangible results when on September 21st, UN Member States convened for the first ever High-Level Meeting on Antimicrobial Resistance (AMR) during the 71st UN General Assembly (UNGA). AMR became the fourth ever health issue to make it onto the agenda of the UNGA, only preceded by major global health issues such as HIV/AIDS, non-communicable diseases, and Ebola. Heads of States adopted a Political Declaration calling for coordinated, global action. You were awarded H.M. The King’s Medal by King Carl XVI Gustaf for your contributions to the betterment of mankind. Antimicrobial resistance, conservatively calculated, causes more than 500,000 deaths every year with one third of neonatal sepsis deaths linked to resistant pathogens. Can you tell us, what is antibiotic resistance? Otto Cars: Ever since the 1940s we’ve been used to be able to treat common bacterial infections such as pneumonia, urinary tract infections, wound infections and sepsis with antibiotics both in the community and in hospitals. Today, successful treatment of these and many other infections is becoming more and more difficult, because of antibiotic resistance, which is a phenomenon that makes these medicines ineffective. But it is not only the successful treatment of individuals that is at stake. Antibiotics are indispensable components of any health system in the world and they’ve been a prerequisite for what we have achieved until today in modern medicine, like major surgery, transplants, cancer chemotherapy and the survival of pre-term babies just to give you a few examples. As you stated, we’re seeing a worrying increasing death toll of resistant bacterial infections worldwide. For too long, this problem has been neglected, and if the situation is not urgently dealt with by governments and international organizations we are facing a true global crisis - not only for public health, but also for global sustainable development and economic growth.YS: What causes antibiotic resistance? OC: Antibiotic resistance is a way for bacteria to avoid the effects of antibiotics. This can be accomplished through several mechanism e.g. by preventing the antibiotic to enter the bacterial cell, or pumping it out of the bacterium. Bacteria can also change the target molecule for the antibiotic, thus preventing it from exerting its effect and they can sometimes also destroy the antibiotic itself, in fact, they break it down. So there are many ways that they can resist effects of the antibiotics. And some bacteria are equipped with several of these mechanics simultaneously. Bacteria are all around us; in the environment, one gram of soil contains millions and millions of bacteria. They are also in us: bacteria are vital components of the human body! An adult person has on average 1.5 kilograms of bacteria in the normal bacterial flora, primarily in the gut and on the skin. In all bacterial populations there will always be some bacteria that have become resistant, and when we treat humans and animals with antibiotics, and disseminate these drugs into the environment, the resistant bacteria has an advantage – they can survive and will be selected. This evolutionary process has been driven by the millions of tons of antibiotics we have used during more than 70 years and as a result we are now facing multi-resistant bacteria spreading globally.YS: You wrote in one of your papers that we’re seeing the “tip of the iceberg” with antibiotic resistance, what do you mean by that? OC: Well, I mean that, although antibiotic resistance undermines the safe treatment of many important diseases, the world has not reacted proportionally to this problem and has not dealt with it in the way it should have. Because antibiotic resistance is not a disease itself, it has not been visible, the major consequences have been emerging under the surface, and thus have not been properly measured and understood until the last five or six years. Today we have strong evidence of the attributable mortality of antibiotic resistance from the EU, US and globally. We can see today that burden of antibiotic resistance falls disproportionally on low-income countries with weak health and sanitary systems, but it has been hidden among many other major health challenges, again being an invisible threat. YS: Why is that important not to use antibiotics unless it’s absolutely necessary?OC: I think the analogy with climate change might be appropriate here. If we look upon effective antibiotics as a global public good, a common, scarce resource, all of us have the responsibility to preserve this resource, because it might not be easily renewable, like fossil fuels. Any antibiotic use will lead to more resistance, so everyone using antibiotics is contributing to resistance development. To slow down and manage this phenomenon, we must take a shared responsibility to avoid unnecessary antibiotic use, which is a big problem everywhere. I believe that continuous awareness- raising efforts toward the general population is really an important tool to make everyone part of the solution. In some countries, antibiotics are readily available over the counter, in pharmacies and in drug shops. If the public becomes aware of when antibiotics should be used or not, the unnecessary demand could be changed and that would be a very good contributions to the solution.YS: Are there clinical practice guidelines that can help healthcare professionals determine whether an antibiotic is needed? OC: Yes, absolutely. Because of increasing resistance among bacteria, the choice of antibiotics is becoming more difficult and guidelines are important both to ensure maximum patient safety but also to avoid unnecessary antibiotic use. Guidelines need to build on good surveillance systems in the hospitals, monitoring dynamically the resistance trends so that physicians can target the treatment, the best way. A great help would be a rapid diagnostic test quickly could guide this decision. This has for too long been a neglected area for research and development, but more diagnostic tools are now becoming available, and it is important that these are implemented in health care since they will contribute both to cost-effectiveness of treatment and to patient safety. YS: Why are we so worried about these “nightmare bacteria”? Are they Gram-negatives?OC: Yes, what’s being called “nightmare bacteria” or “superbugs” in the media is today primarily the Gram-negatives, a group of bacteria that are present, for example, in the gut flora in humans and animals. They have a very complex outer shell which makes it very difficult for antibiotics to enter. They also are more and more equipped with other resistance mechanisms making them multi-resistant. This makes them really difficult to treat, and some of these Gram-negative bacteria that are now travelling around the world are resistance to almost all available antibiotics. This, coupled with the fact that for these specific Gram-negative bacteria, drug development has been standing still for more than 30-40 years, makes the situation really frightening. The pipeline of new antibiotics is definitely not meeting the needs.YS: Should hospital leaders be concerned?OC: Absolutely. Hospital leaders have the responsibility of course to create the safe environment for the patients and minimize the risk for emergence of nosocomial infections including those caused by resistant organisms. Safeguarding the effectiveness of existing antibiotics and minimizing the risk for hospital outbreaks is becoming increasingly important. We really need to see this as a quality issue in healthcare. Optimizing hygienic measures and compliance with infection control practices and supporting systems for prescribing decisions are key responsibilities for hospital leaders.YS: Which populations are at increased risk?OC: The most vulnerable are patient populations with weak immune defenses, for example patients undergoing transplantation or cancer chemotherapy and patients taking other kind of immune suppressive drugs for chronic diseases. Neonates or preterm babies with non-developed immune defenses are also more vulnerable, as are elderly people. When local barriers in the body are broken e.g. during surgery, bacteria from the normal flora could easily spread into the blood causing sepsis. In low-and middle-income countries undernourishment among children is another important factor. YS: What are the real-world challenges facing practicing clinicians?OC: Today, clinicians all over the world are facing problems with increasing resistance and are becoming increasingly worried that the antibiotics currently available for treatment are not going to work. In high-income countries with well-developed health systems and with access to combinations of antibiotics to treat multi-drug resistant bacteria, the risk of treatment failure and serious consequences can still be minimized. The situation is much worse in low-income countries where the latest antibiotics are often not available or affordable and where weak infection control and lack of basic sanitation are paving the way for the spread and outbreaks of these bacteria. What has happened during the last 5 years or so, is that the world is waking up to see this is a truly global problem, which needs a global solution. Without this, we won’t succeed because resistant bacteria are developing and spreading in all regions.YS: You also wrote, “The world is accountable for the present-day crisis of ABR by a failing public policy, global governance, research prioritization, and market system.” What is being done to control ABR at the WHO? Can you also explain the Global Action Plan on Antimicrobial Resistance?OC: Yes, clearly the world has failed to understand the dimensions of the antibiotic crisis and the WHO has not been showing the leadership that was expected. Already in 2001, a global strategy was published, and although the expert knowledge was already there, it didn’t translate into governmental action, research prioritization, and the necessary financial resources. Coming back to what we discussed before, this inability was probably caused partly by the lack of data on the disease burden caused by antibiotic resistance. So we have been losing many, many years and the Global Action Plan on Antimicrobial Resistance, adopted by the World Health Assembly in May 2015 is an extremely important step forward. It’s a really important plan. It’s well-structured and it is a giving guidance to governments on actions in all the different areas needed to manage the problem. Of course all national governments need to do their part, but it is a major challenge for weak economies to deal with this complex problem where health systems, surveillance and regulation need to be strengthened and where funding is needed for this capacity building. Therefore, we need to create global mechanisms to support low-income countries and to fund research and development of new technologies. A high level meeting on antimicrobial resistance will be held in the United Nations General Assembly on September 21st. My hope is that in addition to the WHO, other UN agencies such as UNICEF, UNESCO, UNDP and the World Bank will now get truly involved in this global problem, and contribute with their knowledge and capacity.YS: That kind of leads me to my next question. Besides funding, what else can the UN do to combat ABR? Please discuss National Surveillance Programs.OC: Surveillance programs are key, without a good understanding of the magnitude of the problem we cannot prioritize our interventions, nor measure their effect, and we need them to regularly update treatment guidelines. There is now a program in development lead by WHO, the Global Antimicrobial Resistance Surveillance System (GLASS) which needs to be speeded up. It will take some time, because it builds on data from quality assured laboratories, and in some countries there are no such laboratories at all. So, I think what we need, while awaiting the results from this system, is a quick global sentinel-based study with representative samples from different regions to get a picture of the resistance levels to guide therapy in countries where there is no data. Because today in many countries, physicians, pharmacists and other healthcare workers do not really know which antibiotics really work.YS: How about education among health-care professionals, the general public, hospital leaders etc.?OC: As said before, I think everyone has a role to manage the problem, so increasing the understanding through education and awareness-raising is a key factor. This could be done through targeted campaigns towards different stakeholders, but news media also has a significant role. Antibiotic resistance should be a compulsory component in schools and in all curricula of healthcare students, which is still not the case.Of course it need to be contextualized, I mean the messages couldn’t be the same in Ghana as in Sweden or the US, they need to be adapted to the local situation and culture. But in the end, we need to change behavior and social norms with regard to antibiotics everywhere. It should not be acceptable to take an antibiotic course for a viral infection where the only effect is to drive resistance. It took a long time for us to realize the severe effect of climate change, hopefully we will act quicker on the antibiotic crisis. It is not somebody else´s problem, we all are responsible for our part of the solution.YS: “Interagency task forces”, “intersectional collaborations” are bodies you believe are needed to ensure implementations of action on antibiotic resistance on a national level. What sort of agency do you see that can collaborate to bring more awareness and provide resources to antibiotic resistance?OC: I think one of the problems with antibiotic resistance is that it has been confined to the health area and therefore a responsibility primarily of health ministers. Of course, in its core, it’s a health issue but both the causes and the consequences of antibiotic resistance reaches far beyond the health sector, it’s a societal issue. Today there is also a better understanding of the ecological dimensions of the problem, we are talking about the one health concept, which includes humans, animals and the environment. But on the governmental level this is not sufficient, we need to broaden the responsibility even more, including not only the ministers of health, agriculture and environment, but also others such as ministers of research and education, development aid ,foreign affairs, and the not the least ministers of finance. There need to be a broad intergovernmental action plan and sufficient human and financial resources allocated for its implementation. And similarly, as we just discussed, on the global level a broad collaboration between UN agencies and other international bodies need to be formed to manage this problem.YS: You’ve used the term “political courage”. What do you mean by that?OC: What we need is political will and political courage. During the last five years lot of documents and declarations have been produced, a lot of meetings have been organized but tangible global collaboration is still missing. We cannot solve antibiotic resistance, it will stay with us as long we are using these medicines. Thus we can only manage it, achieving a balance between supply and demand. This will cost a lot of money, but much less if we act today than if we allow the problem to continue to grow. The resource-rich countries need to take responsibility and must be willing take the risk of financing much of what is needed to be done. But all countries must be willing to take unpopular decisions such as stronger regulations, targets for antibiotic use, removing misaligned financial incentives etc. This is a difficult political issue, which needs courageous politicians.YS: I know for global warming it took some well noted politicians, including the former U.S Vice-President Al Gore, to bridge the gap between science and policy. How do you envision this for antibiotic resistance?OC: Yes, bridging the gap between science and policy is exactly what has been missing for many years. But in fact, we are now in a situation where scientists, health activists and champions in many countries have helped to “translate” a technically complex issue into political understanding and action. The AMR Review, commissioned by the UK Prime Minister, has contributed significantly to this. So, hopefully we can move from awareness-raising to policy implementation and what we need now is and international group of champions with the mandate and capacity to coordinate this on the global scale and mobilize the resources needed. YS: Let’s turn our attention to the international network ReAct. Can tell our readers about it?OC: I think it’s quite a unique network, it’s 10 years old, initiated in 2005. The primary reason for its establishment was that not much really happened after the publication of the global strategy to contain antimicrobial resistance by the WHO in 2001. We were building on experience from Sweden and some EU countries of the consequences and nature of the problem and how to deal with it, and started to engage policy makers, health activists and civil society organization in different regions of the world. ReAct has since the beginning been in close contact with the WHO and supported the organization in many projects. We aim for profound change in awareness and action to manage the interacting social, political, ecological and technical forces that drive the rising rate and rapid spread of resistant infections. ReAct, still a small network building on much voluntary work, is today organized in five regional nodes: Europe, United States, Latin America, South East Asia and Africa. The major funding comes from the Swedish International Development Cooperation Agency, SIDA. A core part of our work has been gathering evidence on the global consequences of antibiotic resistance, to translate this to into a broader understanding and supporting other groups and organizations to take actions. In this way, ReAct is a growing network of networks. We have also been working quite strongly and consistently to make the world aware of the problem with the innovation failure regarding new and urgently needed antibiotics, and the need for a radically new economic model to be able to deal with this crisis. In 2009, we worked together with the European Medicines Agency and the European Center for Disease Preventions and Control on a report that analyzed for the first time the health and economic burden of antibiotic resistance and the status of the pipeline of antibiotic development. I think that was very valuable report, because it laid down clear evidence of the situation. I think we have also been quite successful in making people understand that public and private sectors need to collaborate, and that the return of investment for newly developed antibiotics must be de-linked from volume sales, to conserve new drugs by avoiding rapid resistance development.YS: What is status of the development of new antibiotics?OC: We have an innovation crisis. Its major cause is the scientific challenges related to finding antibiotic candidates for treatment of multi-resistant Gram-negatives. Many major pharmaceutical companies have abandoned the field, and the global infrastructure for research and development of new antibiotics is weak, few scientists today are experts in the field. What we need is completely new chemical classes of antibiotics, but this is not easy. Following an EU conference in Sweden in 2009, the European Commission launched an action plan including significant funding for a public private partnership for antibiotic development, New Drugs for Bad Bugs (ND4BB). Recently a collaboration (CARB-X) was launched between the US National Institute of Allergy and Infectious Diseases (NIAID) and the Biomedical Advanced Research and Development Authority (BARDA) and four life science accelerators in the US and UK. We are now hopefully moving towards an open global collaboration to facilitate knowledge-sharing and avoiding duplication of expensive mistakes. However, these initiatives will not be sufficient, more will be needed to solve the antibiotic innovation crisis.YS: How about plans to promote new vaccines?OC: Of course prevention is much better than treatment. First of all we have to increase the implementation of the vaccines that already available! The pneumococcal vaccine is a great success, it has significantly reduced the numbers cases of pneumonia in children, but it’s not implemented globally the way it should. It is still too costly for many low-income countries, despite the fact that it could save numerous lives and avoid unnecessary antibiotic treatments. We also need more bacterial vaccines, but the pipline is unfortunately not very promising. This is another research area that has been neglected for long and needs to be strenthened significantly.YS: Is there a role for bacteriophage in the fight against antibiotic resistance?OC: There is an increasing interest for bacteriophages and other alternatives antibiotics, but they have so far only been promising for local application, such as wound infections. Also, they are very bacteria-specific, which means that we need precise diagnostic tools that can identify the pathogens rapidly to be able to make optimal use of them. I think therefore, that for many years to come, we need to rely on “classical” antibiotics for severe infections.YS: What are the main myths of antibiotic resistances that you’d like to dispel?OC: The first myth, or misconception I am thinking of, which is also one of the major causes of the resistance problem, is that all infections giving you fever should be treated with antibiotics. Here there are still major knowledge gaps to overcome worlds-wide. A second myth is the statement in numerous articles and policy documents that you have to take the full course of antibiotics to minimize the risk for resistance development. Although it is clearly true for a very special type of infection, tuberculosis, which requires many months of treatment, it is not relevant for other bacterial infections. Instead, long treatments periods will select more resistant bacteria in the normal commensal bacterial flora and the treatment period needs to be as short as possible. Of course, patients should complete the course recommended by the prescribing physician, but more studies are needed to find the optimal treatment times. What is true however, is that too low antibiotic doses, such as could be the case when substandard or counterfeit drugs are given, is an increased risk factor for resistance development. Thirdly, many people still believe that the pharmaceutical industry will continue to deliver new antibiotics when the old ones have become useless because of resistance. This is definitely not the case and a dangerous self-deception.YS: In all your years working with antibiotic resistance, what surprised you the most?OC: What actually has surprised me the most, and a question I am often asked, is why the WHO, who produced a very good strategy in 2001 was not able to generate momentum for the issue. I still don’t have the answer, but it was a great frustration, that became the incentive for starting ReAct.YS: How optimistic are you about securing a world free from fear of untreatable infections?OC: We have to be realistic. Although the nature of the problem, its causes and consequences are now much better known than ever before, it is a great challenge to mobilize the funding and global collaborations needed, where national interests need to be put aside for the global public good. If the scientific challenges for development of new antibiotics can be solved, it will still take many years to develop a novel antibiotic and make it available to patients. So, I believe that during the next 5-10 years, health care globally will face increasing problems with antibiotic resistance. Securing a world free from fear of untreatable infections is still ReAct´s vision. The increasing awareness and actions on the political level during the last few years gives some optimism that we are now moving in that direction.YS:Dr. Cars, on behalf of The SafeCare Group and SafeCare magazine, I thank you for devoting the last two decades contributing to the betterment of mankind as you spread the word about the risk of antibiotic resistance and we tackle the problem head-on.

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Antimicrobial Resistance

An estimated 700,000 people worldwide die each year from antibiotic resistant bacteria, with most deaths happening in inpatient healthcare settings, such as hospitals and nursing homes. Modelling up to the year 2050, by Rand Europe and auditors KPMG, suggested 10 million people could die each year - equivalent to one every three seconds. David Cameron, Former UK Prime Minister stated, “If we fail to act, we are looking at an almost unthinkable scenario where antibiotics no longer work and we are cast back into the dark ages of medicine." Professor Dame Sally Davies, the UK Chief Medical Officer warned in January 2013 that the rise of antibiotic-resistant superbugs could lead to an “apocalyptic scenario” in which people would die of minor infections and basic operations would become deadly. She expressed the urgency of tackling antimicrobial resistance when she states, “We have reached a critical point and must act now on a global scale to slow down antimicrobial resistance.”An urgent 114 page report from the Centers for Disease Control and Prevention (CDC) details the potential threat posed by antibiotic-resistance microbes. The report, Antibiotic Resistance Threats in the United States, is a synopsis of the cause and harmful consequences of antibiotic over prescription and the development of antibiotic-resistant organism. According to the CDC, more than 2 million Americans are infected with bacteria that resist antibiotics. The agency claimed antibiotics are among the most commonly prescribed drugs used in human medicine and can be lifesaving drugs. However, up to 50% of the time antibiotics are not optimally prescribed, often done so when not needed, incorrect dosing or duration. The CDC report outlined the top 18 drug-resistant antimicrobial threats to the United States. These threats were categorized based on level of concern: urgent, serious, and concerning. Three superbugs represented “urgent threats” - Clostridium difficile, carbapenem-resistant Enterobacteriaceae (CRE), and Neisseria gonorrhoeae.

​A 2015 CDC study found that C. difficile caused almost half a million infections among patients in the United States in a single year. An estimated 14,000 deaths are directly attributable to C. difficile infections, making it a substantial cause of infectious disease death in the United States. The CDC estimated that up to $3,800,000,000 in medical costs could be saved over 5 years.

Untreatable and hard-to-treat infections from carbapenem-resistant Enterobacteriaceae (CRE) bacteria are on the rise among patients in medical facilities. CRE have become resistant to all or nearly all the antibiotics we have today. Almost half of hospital patients who get bloodstream infections from CRE bacteria die from the infection. Neisseria gonorrhoeae causes gonorrhea, a sexually transmitted disease that can result in discharge and inflammation at the urethra, cervix, pharynx, or rectum.

​Several reasons were cited for unnecessary antibiotic prescription and utilization:1. Doctors ordering antibiotics and not confirming with laboratory test that bacteria are causing the infection.2. Patients demanding treatment for viral and non-bacterial conditions such as a cold when antibiotics are not helpful.3. Healthcare practitioners being too willing to satisfy a patient’s expectation for an antibiotic prescription (fear of litigation).The Joint Commission unveiled its new Medication Management (MM) standard (MM.09.01.01) for hospitals, critical access hospitals, and nursing care centers which addresses antimicrobial stewardship. This standard was developed following the White House Forum on Antibiotic Stewardship, held on June 2, 2015 and is effective Jan. 1, 2017. The elements of performance (EPs) address:• Leaders establishing antimicrobial stewardship as an organizational priority.• Educating staff and licensed independent practitioners involved with ordering, dispensing, administering and monitoring antimicrobial resistance and stewardship practices.• Educating patients and families on appropriate use of medications, including antibiotics.• Creating a multidisciplinary, antimicrobial stewardship team.• Developing an antimicrobial stewardship program.Inpatient Healthcare Providers should:

Know what types of drug-resistant infections are present in their facility and patients.

Alert receiving facility when patients are transferred with a drug-resistant infection.

Protect patients from drug-resistant infections.

Follow relevant guidelines and precautions at every patient encounter.

Prescribe antibiotics wisely.

Remove temporary medical devices such as catheters and ventilators as soon as they are no longer needed. ​

The CDC’s Five Key Moments for improving the cycle of antibiotic prescribing practices in hospitals:

Upon admission, assess patient for signs and symptoms infection.

Make sure that culture results represent true infection and not just colonization.

Follow practice guidelines and prescribe antibiotics indicating the dose, duration, and indication in the patient record.

In keeping with the antibiotic stewardship policy, reassess the prescription the next day.

Review notes at handoffs with a different caregiver, showing dose, duration, and indication.

​The SafeCare Group and the CDC recommends four Core Actions to battle antibiotic resistance:1. Preventing Infections, Preventing the Spread of Resistance: Avoiding infections reduces the amount of antibiotics that have to be used and reduces the likelihood of antibiotic-resistant organisms.2. Tracking: CDC monitors antibiotic-resistant infections, and recommends management through evidence-based strategies (addressed through The SafeCare Group ValueTrax I software).

​3. Improving Antibiotic Use: This is perhaps the most important action to impact the development and spread of antibiotic-resistant organisms. Effective is a two-pronged approach consisting of curtailing unnecessary prescriptions of antibiotics (addressed through the CDC Get Smart program), and monitoring adverse drug events (addressed through The SafeCare Group ValueTrax III software).4. Development of better diagnostic testing and antibiotic regimens.Other SafeCare Group strategies include - Infection control including the CDC/WHO hand hygiene practices, early detection and treatment of resistant infections, monitor and manage adverse drug events.

hospital spotlight - parrish medical center

Parrish Medical Center (PMC) is a public, not-for-profit, 210-bed acute care hospital located within sight of the launch towers of Kennedy Space Center in Titusville, Florida. A Mayo Clinic Care Network member and one of the nation’s most recognized hospitals for clinical quality, patient safety and healing environments, PMC has served Brevard County for nearly 60 years. Parrish continues to achieve a level of excellence on par with the nation’s very best hospitals. Just this year, PMC established Parrish Healthcare, a groundbreaking network of healthcare providers certified by The Joint Commission as the nation’s first Integrated Care Network. Parrish Healthcare includes Parrish Medical Center, Parrish Medical Group, and Florida Health, a regional network of health providers and insurers.Through its culture, Parrish Healthcare Care Partners (employees, medical staff and volunteer auxiliary) have created a culture of healing in order to live the vision established by its Board of Directors. Parrish Healthcare’s culture journey is one characterized by a desire to create unique healing experiences for patients, families, visitors and caregivers; leadership that is identified by integrity, honesty, courage, and humility; and a mechanism for process improvement through a strategic game plan.

The leadership of our Governing Board and Executive Management Team has provided the framework and commitment to safe and effective patient care. When outcome standards are set they are based on top decile outcomes at a national level. This continues throughout the organization including many evidence based practices such as daily multidisciplinary team rounds on all patients, hourly/purposeful rounding by nurses and CNA’s, and our Patient and Family Advisory Counsel (PFAC).Though honors and accolades were never the end goal in carrying out its mission Parrish Healthcare has naturally become recognized among America’s finest healing environments. Among its many accolades:

Since 2015, PMC has earned top rankings on The SafeCare Group’s 100 SafeCare Hospitals® ranking top performer among Florida hospitals in CMS HVBP, HRRP, and HACRP. It was also the only Florida hospital to attain the coveted 3 standard deviations above the average cumulative score with 40 metrics of the Affordable Care Act.

The Joint Commission awarded PMC the first ever certification for Integrated Care and has consistently recognized PMC as a Top Performer on Key Quality Measures, as well as awarding multiple disease-specific Gold Seal advanced certifications, including for Primary Stroke.

Since the rankings began in 2012, the hospital has earned straight-A safety ratings from the Leapfrog Group, an independent, national not-for-profit organization founded more than a decade ago by the nation’s leading employers and private healthcare experts. This makes PMC one of only 133 (out of more than 5,000) hospitals in the nation and one of 15 in the state of Florida to have done so.

Parrish is ranked a Vizient Hospital Engagement Network Top Performer in a number of measures tracked as part of the Centers for Medicaid and Medicare Services (CMS) Partnership for Patients initiative.

Parrish ranks among the top “150 Great Places to Work in Healthcare” by Becker’s Hospital Review 2016, a premier national healthcare publication.

Parrish was honored with the 2016 Women's Choice Award for being one of America's Best Stroke Centers. The Women’s Choice Award is the only declaration that integrates clinical excellence (CMS) and consumer experience (HCAHPS).

​Mission, Vision, Values Parrish Healthcare’s journey began shortly after moving into Parrish Medical Center’s replacement hospital in 2002. This journey was never about changing the culture, but about how to continuously make the culture healthier. Healthcare is a calling to serve. Unlike any other profession, healthcare providers are invited to share in the most profound moments in people's lives. That's why Parrish Healthcare Care Partners dedicate themselves to fulfilling their mission through the values of Safety, Loyalty, Integrity, Compassion, Excellence and Stewardship. Parrish Healthcare uses Lean Six Sigma as the methodology to ‘power’ the way we way go about fulfilling our mission, vision and values.Groundbreaking Integrated Care Certification In January 2016, Parrish Medical Center earned the nation’s first Joint Commission integrated care certification and announced the formation of Parrish Healthcare, a regional network of integrated care partners. Parrish Healthcare includes Parrish Medical Center; Parrish Medical Group, NCQA-certified as a patient-centered medical home; and Florida Health Network®, a regional network of healthcare providers, insurers and others, including the Mayo Clinic in Jacksonville, Florida, working collaboratively to improve quality and safety while lowering healthcare costs on behalf of individuals, families and businesses.The certification recognizes hospitals and ambulatory care settings that excel at integrating information-sharing and transitions of care as a patient moves between the hospital and outpatient care settings. The significance of this seamless and flowing river of service has critical importance to patients’ health outcomes. While many hospitals tout an integrated care system, Parrish is the nation’s first, and currently the only one, to be integrated care certified, attesting to the hospital’s “walk-the-walk” philosophy versus the “talk-the-talk” approach of other healthcare organizations. “Unlike most models that build fragmented networks through mergers and acquisitions, Parrish Healthcare’s model is one of collaboration among health and healthcare organizations with the patient and his or her personal health and wellness goals at the center of that collaboration,” said George Mikitarian, president and CEO of Parrish Healthcare. “We are proud to be the nation’s first to earn Integrated Care Certification. We wanted a tough, objective measure of our integrated care effectiveness. Completing the voluntary certification process continues to afford us the opportunity to demonstrate that our community-based network of hospitals, physicians and outpatient services are effectively working together to improve patient care and quality and to reduce costs.”

The rigorous and exhaustive certification process validated Parrish’s leadership as a provider of patient-centered, compassionate and effective care. “We have dedicated ourselves years before the passing of the Affordable Care Act to the goal of transforming how we provide health-related services, healthy living initiatives, as well as safe, high quality and healing care, in direct cooperation with the people we serve,” added Mikitarian. PMC believes that goal is best achieved through integration, coordination and collaboration of health-related care programs throughout the individual’s life. Research has proven that collaboration between healthcare providers, for the benefit of people—individuals, families and communities—is preferable to costly competition between organizations and uncoordinated care that raises costs and does little to improve a person’s health. “Collaboration has been one of our strategic initiatives well before the enactment of the Affordable Care Act. The Integrated Care Certification validates what we’ve been doing for a long time,” said Mikitarian.Achieving Greatness Parrish Healthcare’s quality, safety, service, and low-cost excellence result from years of focus on its strategic game plan to guide how it fulfills the mission. Each month, every hospital department reviews a matrix of clinical care, safety, patient experience and cost measurements. That focused attention is what allows the organization to consistently achieve the level of success and excellence for its patients, their families and the community. Where metrics are not meeting goals, Care Partners identify, analyze and work to improve processes. Every Parrish department head is required to be Lean Six Sigma Green Belt certified. This creates a foundational competency to support Parrish’s continuous improvement culture, whih in turn results in high reliability systems of safe care.

Top Performer for Quality Improvements Among the many quality improvement initiatives with which Parrish participates, its Care Partners earn top rankings. As an example, Parrish ranks as a top performer by CMS Partnership for Patients initiative. A “top performer” hospital is one that sustained a zero (0) rate for the past four quarters for a given outcome measure in a Partnership for Patients Area of Focus. As a top-ranked performer, PMC has maintained a zero rate for Catheter-Associated Urinary Tract Infections (CAUTI), Central Line-Associated Bloodstream Infection (CLABSI) and Ventilator-Associated Pneumonia (VAP) for the past eight quarters. The federal Partnership for Patients initiative is a partnership with more than 3,700 participating hospitals that are working to improve the quality, safety and affordability of healthcare for all Americans. PMC’s achievements beyond the recent top performer ranking for specific measured areas include:

No central line-acquired blood stream infections during the past three years

No catheter-associated urinary tract infections (UTIs) in the past four years

No instances of ventilator-associated pneumonia in the past eight years

Achievements such as the elimination of Hospital Acquired Infections/Conditions are not by accident. PMC’s commitment to Lean/Six Sigma performance improvement methodologies are the process we have committed to from our Strategic Plan (Game Plan) to individual patient safety improvements. For the three items above we initiated 100 day workouts to implement evidence based practices and used PDSA cycles to establish the practices that worked for our patient population. The PDSA cycles have continued over time to assure we protect every patient all the time. “Parrish’s excellent scores are a direct result of diligent work by our Care Partners,” stated Edwin Loftin, Vice President, Acute Care Services/CNO for Parrish Medical Center. “Our team of Care Partners consistently earns top rankings with CMS and other rating agencies for quality and safety, not only in Central Florida, but nationally. Making care safer, more reliable, and less costly is what we work to achieve every day. Being part of the Partnership for Patients initiative has allowed us to provide safe, more effective care for the communities we serve at a lower cost.”